EP0751785B1 - Combinaisons de proteines et d'anticoagulants actifs sur le plan thrombolytique, et leurs utilisations - Google Patents

Combinaisons de proteines et d'anticoagulants actifs sur le plan thrombolytique, et leurs utilisations Download PDF

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EP0751785B1
EP0751785B1 EP95912261A EP95912261A EP0751785B1 EP 0751785 B1 EP0751785 B1 EP 0751785B1 EP 95912261 A EP95912261 A EP 95912261A EP 95912261 A EP95912261 A EP 95912261A EP 0751785 B1 EP0751785 B1 EP 0751785B1
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Prior art keywords
anticoagulant
heparin
administration
active protein
hirudin
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EP0751785B2 (fr
EP0751785A1 (fr
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Ulrich Martin
Stephan Fischer
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Roche Diagnostics GmbH
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Roche Diagnostics GmbH
Boehringer Mannheim GmbH
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/55—Protease inhibitors
    • A61K38/57—Protease inhibitors from animals; from humans
    • A61K38/58—Protease inhibitors from animals; from humans from leeches, e.g. hirudin, eglin
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/43—Enzymes; Proenzymes; Derivatives thereof
    • A61K38/46—Hydrolases (3)
    • A61K38/48—Hydrolases (3) acting on peptide bonds (3.4)
    • A61K38/49—Urokinase; Tissue plasminogen activator
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P7/00—Drugs for disorders of the blood or the extracellular fluid
    • A61P7/02—Antithrombotic agents; Anticoagulants; Platelet aggregation inhibitors
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P9/00—Drugs for disorders of the cardiovascular system
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P9/00—Drugs for disorders of the cardiovascular system
    • A61P9/08—Vasodilators for multiple indications
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P9/00—Drugs for disorders of the cardiovascular system
    • A61P9/10—Drugs for disorders of the cardiovascular system for treating ischaemic or atherosclerotic diseases, e.g. antianginal drugs, coronary vasodilators, drugs for myocardial infarction, retinopathy, cerebrovascula insufficiency, renal arteriosclerosis

Definitions

  • the present invention relates to compositions and methods for the preparation of a pharmaceutical combination for the treatment of patients with acute occlusive vascular diseases. These are characterized by administration of an anticoagulant agent, which is not heparin, via intravenous bolus injection instead of prolonged intravenous infusion, in combination with thrombolytically-active protein which may be given by intravenous bolus injection and/or by intravenous infusion.
  • an anticoagulant agent which is not heparin
  • Cardiovascular diseases such as acute myocardial infarction, stroke, peripheral arterial occlusion, pulmonary embolisms, deep vein thrombosis, and other blood vessel thrombotic diseases are major causes of morbidity and mortality.
  • the aforementioned diseases are caused by total or subtotal occlusive thrombus formation in a blood vessel, which prevents delivery of an adequate blood supply to the tissue.
  • the thrombus consists of aggregates of blood cells such as platelets, erythrocytes and leukocytes, stabilized by a fibrin network.
  • Thrombolytic therapy of acute myocardial infarction has been shown to markedly improve the natural history of acute myocardial infarction, with an approximately 30 % reduction in mortality (GISSI: Lancet 1986; 1: 871-874; ISIS-2: Lancet 1988; 2: 349-360; AIMS: Lancet 1988; 1: 545-549; Wilcox et al., Lancet 1988: 2: 525-539; ISAM: N Engl J Med 1986; 314: 1465-1471).
  • Pharmacological approaches to enhancing velocity and quality of thrombolysis can, in general, be based upon the thrombolytic agent itself and upon adjunctive agents, i.e., other agents given concomitantly to the thrombolytic agent.
  • rt-PA tissue-type plasminogen activator
  • rt-PA Recombinant tissue-type plasminogen activator
  • ISIS-3 Lancet 1992: 339: 753-770; GUSTO: N Engl J Med 1993; 329: 673-682
  • a novel thrombolytically active protein such as the novel recombinant plasminogen activator BM 06.022 (also designated as rPA), described in US Patent No. 5,223,256 and incorporated by reference, was shown to achieve very high patency rates after double bolus administration (Bode et al., Circulation 1993; 88 (suppl. I): I-292, abstract 1562).
  • aspirin and heparin are limited. This is attributable to their modes of action. Aspirin only inhibits one pathway of activation of platelets (by inhibition of cyclooxygenase). The action of heparin is dependent on the availability of antithrombin III. The restricted efficacy of heparin is also caused by the presence of inhibitors in plasma and its limited access to clot-bound thrombin.
  • novel antiplatelet agents such as antagonists of the glycoprotein IIb/IIIa receptor (e.g., antibodies, peptides, or low molecular weight chemical entities) and in novel anticoagulants (peptidic and synthetic direct inhibitors of thrombin and other components of the coagulation system, such as inhibitors of factor Xa, IXa, VIIa, tissue factor, etc., or mimics of endogenous inhibitors of the coagulation system, such as activated protein C or thrombomodulin).
  • antagonists of the glycoprotein IIb/IIIa receptor e.g., antibodies, peptides, or low molecular weight chemical entities
  • novel anticoagulants peptidic and synthetic direct inhibitors of thrombin and other components of the coagulation system, such as inhibitors of factor Xa, IXa, VIIa, tissue factor, etc., or mimics of endogenous inhibitors of the coagulation system, such as activated protein C or thrombomodulin.
  • hirudin a recombinant protein which directly inhibits clot-bound thrombin
  • hirudin has a short half life of 10 - 15 minutes in dogs (Biomed Biochim Acta 1987; 46: 237-244 and Folia Haematol 1988; 115: 70-74) and of 9 - 50 minutes in humans (Thromb Haemost 1984; 52: 160-163).
  • the present invention provides pharmaceutical compositions and methods for the preparation of a pharmaceutical combination for treatment of a patient with a thrombotic disease.
  • the pharmaceutically effective compositions, for treatment of a patient with a thrombotic disease are characterized by administration of an i.v. bolus injection instead of prolonged i.v. infusion of a potent and effective anticoagulant agent which is not heparin, in combination with a thrombolytically active protein, which may be given by i.v. bolus injection and/or i.v. infusion.
  • This method is useful because it reduces the amount of anticoagulant necessary without loosing the desired pharmacological effect of enhancing reperfusion and preventing reocclusion. Thereby, and most surprisingly, this reduces the bleeding risk, i.e. it improves the safety of the treatment.
  • a lower price (possible by the lower amount of protein) for the treatment and the improved risk/benefit ratio enables more widespread use of this method resulting in reduction of mortality.
  • this method simplifies the administration of the novel anticoagulant, thus only offering more convenience but also permitting more frequent and more effective treatment of patients, thereby saving many lives.
  • the present invention relates to therapeutic or prophylactic compositions and methods for the preparation of a pharmaceutical combination for treating or preventing thrombotic diseases. More particular, the present invention relates to pharmaceutically effective compositions and methods for the preparation of a pharmaceutical combination for treatment or prophylaxis of thrombotic diseases characterized by the combined administration of an anticoagulant agent different from heparin, given by i.v. bolus injection instead of prolonged i.v. infusion, and a thrombolytically active protein given by i.v. bolus injection and/or i.v. infusion.
  • the present invention provides compositions and methods for the preparation of a pharmaceutical combination for treatment of patients with thrombotic diseases which confer the advantages of reducing the amount of novel anticoagulant agents, but maintaining the desired pharmacologic effect, of reducing the costs of therapy, of enhancing convenience of administration of the novel anticoagulant drug and, most importantly reducing the bleeding risk. All of these advantages will considerably contribute to more widespread use of thrombolysis which will help save more lives.
  • Thrombotic diseases in the meaning of the present invention include acute myocardial infarction, stroke, peripheral arterial occlusion, pulmonary embolism, deep vein thrombosis, and other blood vessel thrombotic diseases which have a risk of reocclusion or recurrent thrombus formation after successful thrombolysis.
  • the restriction of the administration of the non-heparin anticoagulant, e.g., hirudin, solely to an i.v. bolus injection instead of initial bolus injection plus continuous i.v. infusion over hours leads to greater safety for the patient by reducing the bleeding risk.
  • the reduced bleeding risk results from a shorter duration of inhibition of the coagulation system, a more rapid normalization of the coagulation system, and a lower influence on the bleeding time.
  • the restriction of administration of the novel anticoagulant solely to an i.v. bolus injection instead of the administration of i.v. bolus injection plus continuous i.v. infusion has maintained the superior effect of prevention of reocclusion by use of novel anticoagulants given as i.v. bolus injection plus infusion compared to that of conventional adjunctive treatment with aspirin plus heparin which still is associated with reocclusion.
  • Anticoagulants different from heparin encompassed by the present invention include peptidic and synthetic direct inhibitors of thrombin and inhibitors of other components of the coagulation system such as inhibitors of factor XIIIa, Xa, IXa, VIIa, tissue factor, von Willebrand factor (glycoprotein Ib) etc., or mimics or recombinant forms of endogenous inhibitors of the coagulation system, e.g. thrombomodulin or activated protein C.
  • proteins preferably proteins, peptides or low molecular weight chemical entities which are produced by recombinant DNA technology, by isolation and purification of substances from natural sources, by peptide synthesis, chemical modification or by conventional chemical synthesis.
  • Preferred anticoagulants are natural forms of hirudin (Markwardt, Methods Enzymol 1970; vol. 19: 924-932 and Markwardt, Biomed Biochim Acta 1985; 44: 1007-1013), more particularly, recombinant forms of hirudin such as desulfatohirudin (which lacks the sulfate on the tyrosine 63 residue of natural hirudin but has the same amino acid sequence as natural hirudin) (variant 1), CGP 39393 (Thromb Haemost 1989; 61: 77-80), or forms which differ from natural hirudin in amino acid 1 and 2, leucine and threonine such as, HBW 023 (Markwardt et al., Thromb Res 1988; 52: 393-400 and Röthig et al., Hämostaseologie 1991; 11: 132-136).
  • HBW 023 Markwardt et al., Thromb Res 1988; 52: 393-400 and Röthig
  • Desulfatohirudin can be produced in eukaryotic cells, e.g., Saccharomyces cerevisiae, or in bacterial cells, e.g., Escherichia coli.
  • Other useful cell lines include Bacillus subtilis, baby hamster kidney cells, insect cells and others.
  • Hirudin and desulphatohirudin consist of a single polypeptide chain of 65 amino acids with three disulfide bridges having a molecular weight of about 7,000.
  • the present invention also relates to modified forms of hirudin such as deletion or substitution variants of hirudin and to chimeric or chemically-conjugated variants, e.g. PEG-hirudin or PEG-hirudin fragments.
  • the present invention is also particularly related to hirulog and hirulog-like peptides (Maraganore et al., Biochemistry 1990; 29: 7095-7101 and Bourdon et al., FEBS letters 1991; 294: 163-166).
  • Hirulog is a 20 amino acid synthetic peptide thrombin inhibitor (D-Phe-Pro-Arg-Pro-[Gly]4 coupled to residues 53 - 64 of the HV2 hirudin variant).
  • thrombin inhibitors are derivatives of 3-amidinophenylalanine (Szebecher et al., Thromb Haemost 1993; 69: 1316, abstract 2773), or the novel Thrombin-inhibitor "RTl" (Tschopp et al., Thromb Haemost 1993 69: 668, abstract 456), and other synthetic direct thrombin inhibitors.
  • Preferred anticoagulants also include natural and particularly recombinant forms of selective, tight-binding inhibitors of blood coagulation factor Xa, such as Antistasin (Nutt et al., Arch Biochem Biophys 1991; 285: 37-44), and natural and recombinant forms of slow, tight-binding inhibitors, specific for factor Xa, such as tick anticoagulant peptide (Waxman et al., Science 1990; 248: 593-596) and other peptide inhibitors of factor Xa.
  • blood coagulation factor Xa such as Antistasin (Nutt et al., Arch Biochem Biophys 1991; 285: 37-44)
  • natural and recombinant forms of slow, tight-binding inhibitors, specific for factor Xa such as tick anticoagulant peptide (Waxman et al., Science 1990; 248: 593-596) and other peptide inhibitors of factor Xa.
  • Factor Xa can also be inhibited by DX 9065a, an orally active synthetic anticoagulant with a benzamidine type structure (Kim et al., Thromb Haemost 1993; 69: 672, abstract 471) and by other synthetic, direct inhibitors of factor Xa.
  • Inhibitors of factor IXa e.g., Benedict et al., J Clin Invest 1991; 88: 1760-1765
  • factor XIIIa e.g., Shebuski et al., Blood 1990; 75: 1455-1459
  • inhibitors of factor VIIa e.g., Meluch et al., Thromb Haemost 1993; 69: 887, abstract 1244
  • tissue factor e.g., Ragni et. al., Circulation 1993; 88 (suppl.
  • I I-615, abstract 3309), of glycoprotein Ib, or von Willebrand factor, (e.g., Yao et al., Clinical Research 1993; 41: 228A) and other inhibitors of components of the coagulation system are also included in the invention.
  • von Willebrand factor e.g., Yao et al., Clinical Research 1993; 41: 228A
  • anticoagulants useful in the invention are mimics or recombinant forms of endogenous inhibitors of the coagulation system such as recombinant thrombomodulin (e.g., Gomi et al., Blood 1990; 75: 1396-1399), recombinant tissue factor pathway inhibitor (e.g., Haskel et al., Circulation 1991; 84: 821-827), recombinant activated protein C (e.g., Gruber et al., Circulation 1990; 82: 578-585) and other mimics of endogenous anticoagulants.
  • recombinant thrombomodulin e.g., Gomi et al., Blood 1990; 75: 1396-1399
  • tissue factor pathway inhibitor e.g., Haskel et al., Circulation 1991; 84: 821-827
  • recombinant activated protein C e.g., Gruber et al., Circulation 1990; 82: 578-
  • the anticoagulants of the invention are administered in doses of 0.01 to 10 mg/kg over 0.5 to 5 minutes as intravenous bolus injection prior to or shortly after initiation of administration of the thrombolytically active protein.
  • Hirudin, hirulog and related peptides are preferably administered in doses of 0.3 to 6 mg/kg over 0.5 to 3 minutes as an intravenous bolus injection prior to or within 5 minutes after initiation of administration of the thrombolytically active protein. More particularly, hirudin, hirulog and related peptides are administered in doses of 0.5 to 6 mg/kg over 1-2 minutes as an intravenous bolus injection prior to administration of the thrombolytically active protein.
  • Oral administration instead of intravenous bolus injection can be performed with low molecular weight forms of new chemical entities and with peptides in combination with drug delivery systems.
  • Thrombolytically active proteins useful in combination with the anticoagulants in the present invention are those agents known to the skilled artisan, such as recombinant tissue-type plasminogen activator, e.g., Alteplase and silteplase, and others such as anistreplase, streptokinase, urokinase, and pro-urokinase.
  • tissue-type plasminogen activator e.g., Alteplase and silteplase
  • anistreplase streptokinase
  • urokinase urokinase
  • pro-urokinase pro-urokinase
  • the present invention also relates to thrombolytic agents such as recombinant plasminogen activator (rPA), BM 06.022, vampire bat plasminogen activator (e.g., Mellott et al., Arterioscler Thrombos 1992; 12: 212-221) and desmodus (vampire bat) salivary plasminogen activator DSPA (e.g., Witt et al., Blood 1992; 79: 1213-1217) or related forms and TNK variants of tissue-type plasminogen activator (e.g., Refino et al., Thromb Haemost 1993; 69: 841, abstract 1074).
  • rPA recombinant plasminogen activator
  • BM 06.022 recombinant plasminogen activator
  • vampire bat plasminogen activator e.g., Mellott et al., Arterioscler Thrombos 1992; 12: 212-221
  • thrombolytically active protein BM 06.022 described supra. This is a non-glycosylated protein consisting of amino acids 1-3 and 176-527 of wild type human t-PA. Additional thrombolytically active proteins are described in USP 4,970,159; EP-A-0,207,589; AU 61804/86; EP-A-0,231,624; EP-A-0,289,508; JP 63133988; EP-A-0,234,051; EP A 0,263,172; EP-A-0,241,208; EP-A-0,292,009; EP-A-297,066; EP-A-0,302,456; EP-A-0,379,890.
  • E-6010 Sudzuki et al., J Cardiovasc Pharmacol 1991; 17: 738-746
  • YM-g66 Yamamoto et al., Japan J Pharmacol 1993; 63: 135-142
  • SUN-9216 Umemura et al., Stroke 1993; 24: 1077-1082.
  • the doses and administration regimens of the thrombolytic agents include those approved by the health authorities, e.g. 100 mg of Alteplase or 1.5 million U of streptokinase.
  • the dose and administration regimen can vary. Especially preferred is a total dose of 15 to 25 mega units (MU) of recombinant plasminogen activator BM 06.022; more especially preferred is a regimen of 10 + 10 MU boli of BM 06.022.
  • the mode of administration of the thrombolytic agents may be via intravenous injection, single bolus or multiple bolus injection or via intravenous infusion, or a combination of these. Especially preferred is a double bolus intravenous injection of BM 06.022 or of other thrombolytically active proteins.
  • the time interval between the injections of the thrombolytically active protein may be 15 to 60 minutes, more preferably from 20 to 40 minutes, most preferably the time interval may be 30 minutes.
  • hirudin as the novel, more potent and effective anticoagulant different from heparin by i.v. bolus injection with BM 06.022 as the thrombolytically active protein at dosing regimens described above is particularly preferred.
  • the combination of hirulog as the novel more potent and effective anticoagulant different from heparin by i.v. bolus injection with BM 06.022 as the thrombolytically active protein at dosing regimens described above is also preferred.
  • the anticoagulants of the invention are administered as intravenous bolus injection prior to or shortly after initiation of administration of the thrombolytically active protein.
  • the time interval between the injection of the non-heparin anticoagulant and the thrombolytically active protein may be from 1 - 30 minutes, especially 2 - 10 minutes and preferably about 5 minutes.
  • the anticoagulant is administered prior to the administration of the thrombolytically active protein. If the anticoagulant is administered after the initiation of administration of the thrombolytically active protein, the time interval for administration of the anticoagulant is preferably 2 - 10 minutes and especially about 5 minutes after the first administration of the thrombolytically active protein.
  • the administration of the non-heparin anticoagulant as a single i.v. bolus injection may be followed 1 to 2 hours later by standard treatment with heparin in the treatment of acute myocardial infarction, i.e., i.v. infusion of heparin and later by subcutaneous administration, or may be followed directly by subcutaneous administration of heparin.
  • Anticoagulant, as well as antiplatelet agents clinically act as antithrombotic agents but differ in their mode of action, i.e., both actions (inhibition of coagulation and inhibition of platelets) prevent thrombus formation and reocclusion.
  • Antiplatelet agents different from aspirin are given as a single i.v.
  • bolus injection concomitantly with the thrombolytically active protein, i.e., prior to or within 30 minutes of administration of the thrombolytically active protein, and may be followed by administration of aspirin over several days instead of by delayed or prolonged administration of the novel, more potent and effective antiplatelet agent.
  • the novel more potent and effective antiplatelet agents different from heparin are preferably inhibitors of the glycoprotein IIb/IIIa receptor on platelets which mediates platelet aggregation.
  • Such inhibitors of the platelet glycoprotein IIb/IIIa (GP IIb/IIIa) receptor may be antibodies, fragments of antibodies, humanized antibodies or humanized fragments of antibodies to the GP IIb/IIIa receptor, peptides or peptidomimetics acting as antagonists to the GP IIb/IIIa antagonist, and low molecular synthetic new chemical entities inhibiting the GP IIb/IIIa antagonist.
  • Inhibitors of the GP IIb/IIIa receptor are preferably the monoclonal antibody 7E3 or chimeric 7E3 antibody (fragment) to GP IIb/IIIa (Tcheng et al., Circulation 1993; 88 (suppl. I): I-506, abstract 2727), the peptide GP IIb/IIIa antagonists Integrelin (Tcheng et al., Circulation 1993; 88 (suppl. I): I-595, abstract 3200) and the peptide MK-852 (Theroux et al Circulation 1993; 88 (suppl. I): I-201, abstract 1075), as well as the non-peptide mimic of GP IIb/IIIa, MK-383 (Peerlinck et al., Circulation 1993; 88: 1512-1517).
  • GP IIb/IIIa receptors include Ro 43-5054 (J Pharmacol Exp Ther 1993; 264: 501-508), Ro 44-9883 (Thromb Haemostas 1993; 70: 817-821), BIBU 104 (Thromb Haemostas 1993; 69: 975, abstract 1557) and BIBU 52 (Thromb Haemostas 1993; 69: 1072, abstract 1887), SC 49992 (J Pharmacol Exp Ther 1993; 267: 1191-1197) and SC 54684 (Thromb Haemostas 1993; 69: 975, abstract 1558), DMP 728 (Circulation 1994; 80: 3-12), GR 144053 (Thromb Haemostas 1993; 69: 1071, abstract 1884), FR 144633 (Thromb Haemostas 1993; 69: 706, abstract 598), SKF-106760 (Nichols et al. .presented at the Am Soc Pharmacol Exp Ther Meeting,
  • the present invention includes also other inhibitors of GP IIb/IIIa not specifically mentioned herein.
  • Treatment of a patient with a thrombotic disease by a combination, composition and method according to the present invention may include concomitant use of further adjunctive agents, such as antiplatelet agents, e.g., aspirin, and anticoagulant agents, e.g., heparin or low molecular weight heparin, or other drugs, e.g., ⁇ -blockers, angiotensin converting enzyme inhibitors, agents against reperfusion injury and others.
  • further adjunctive agents such as antiplatelet agents, e.g., aspirin
  • anticoagulant agents e.g., heparin or low molecular weight heparin
  • drugs e.g., ⁇ -blockers, angiotensin converting enzyme inhibitors, agents against reperfusion injury and others.
  • Subject of the present invention are also pharmaceutical compositions which contain a thrombolytically active protein in an appropriate container and an anticoagulant in a separate container to be used according to the above-mentioned administration regimens.
  • the dose of the thrombolytically active protein in said first container essentially depends on the therapeutic efficacy of said protein for the treatment of patients with thrombotic diseases.
  • the protein rPA is contained in such a container in an amout of 5 - 20 MU (which corresponds to 8 - 36 mg of the protein).
  • the thrombolytically active protein is provided in two or more separate containers which allow the administration of an appropriate dosage of the thrombolytically active protein in the form of two or more boli injections. These two containers may contain the thrombolytically active protein in the same or different amounts depending on the desired administration regimen.
  • each of the two containers preferably include an effective amount of 10 MU.
  • the first container can be provided in form of a solution ready for injection or, alternatively, as a lyophilisate which is reconstituted prior to administration with an appropriate solution, mostly water for injection purposes, to give the desired injection solution.
  • the lyophilisate as well as the reconstitution solution can contain additional pharmaceutical carrier or adjuvant materials which are useful in order to achieve, for example, an isotonic solution or to stabilize or solubilize the protein in said pharmaceutical composition.
  • Pharmaceutical packaging units prepared in accordance with the present invention consist of an appropriate administration form which contains the thrombolytically active protein, and an appropriate packaging unit which contains the anticoagulant.
  • the two active compounds are preferably present in the packaging unit in two different containers, e.g. glass ampoules. However, depending on the type of active compounds, it may also be possible to provide both compounds in a single dosage form.
  • the pharmaceutical packaging unit contains two or more separate containers, each of which containing the appropriate amount of the non-heparin anticoagulant for the respective bolus injection.
  • the pharmaceutical packaging units contain instructions, for example in the form of a package leaflet prescribed for medicaments from which it follows that the administration of a therapeutically active amount of the thrombolytically active protein advantageously takes place in combination with a bolus administration of an anticoagulant.
  • Pharmaceutical packaging units may additionally contain a separate container for the administration of a pharmacologically effective amount of heparin.
  • pharmaceutical packaging units contain in total three different pharmaceutical agents: First, a thrombolytically active protein, second, an anticoagulant and third heparin.
  • Such packaging units are especially valuable in emergency situations where it is desirable to have a complete set of the pharmaceutical agents to be used for an effective treatment of thromboembolic conditions according to the present invention.
  • the administration of the anticoagulant takes places before, simultaneously or after the administration of the thrombolytically active protein. It has been found that it is especially advantageous when the thrombolytically active protein is administered as a double or multiple bolus injection which is combined with very early anticoagulation, i.e. to administer the anticoagulant before the administration of the thrombolytically active protein. Further, it has been found that it is particularly advantageous in order to prevent reocclusion of the reopened blood vessels, when the thrombolytically active compound is administered in the form of a double or multiple bolus in combination with very early anticoagulation. It turned out that it is even more advantageous when heparin is additionally administered such that a sufficiently high serum concentration is maintained, especially during the time when the thrombolytically active protein is administered.
  • Such information regarding the manner of use can either be given in the information leaflet or as a packing overprint on the medical preparation which can be brought together with medicinal preparations which contain thrombolytically active proteins.
  • pharmaceutical packaging units containing only appropriate administration forms of the thrombolytically active proteins can contain such information e.g. in the form of package leaflets, wherein the combined administration together with anticoagulants according to the present invention is mentioned.
  • pharmaceutical packaging units containing only anticoagulants can contain such information wherein the combined administration together with thrombolytically active proteins and the use according to the present invention is mentioned.
  • a third alternative would be to provide pharmaceutical packaging units which contain a thrombolytically active protein, an anticoagulant and an appropriate information about the combined use of both, e.g. the usual package leaflet.
  • the package leaflets can contain appropriate directions for use of the thrombolytically active protein, the non-heparin anticoagulant in combination with the administration of heparin.
  • Appropriate directions of use of the above-mentioned pharmaceutical agents are essential for commercialization of such pharmaceutical packages containing either the thrombolytically active protein, the non-anticoagulant or heparin or a combination thereof.
  • Commecialization of appropriate pharmaceuticals by pharmaceutical companies is only possible when prior approval of such pharmaceutical agents and the respective administration regimens is achieved by the respective national Health Authroities, such as the FDA in the US or the CPMP Authority in Europe. This includes but is not limited to performing clinical trials according to well-established procedures under the supervision of said pharmaceutical company which lateron intends to commercialize such pharmaceutical agents.
  • This also includes filing of appropriate documentation about the results of such clinical trials with the respective Health Authority in order to get marketing approval.
  • the approval is in many cases restricted to certain administration protocols or regimens which have to be included in printed form in the accompanying information leaflet prescribed for medicaments.
  • galenical formulations for example lyophilisates or solutions in appropriate containers, such as e.g., in ampoules, are preferred.
  • these pharmaceutical formulations contain usual pharmaceutical adjuvants which are suitable for preparation of isotonic solutions, and may also include additional stabilizing and solubilizing agents.
  • the anticoagulants may be formulated in a similar way as solutions ready for use or as lyophilisates which are reconstituted with water prior to their use.
  • the present example provides pharmacological evidence of the surprising and superior effect of pharmaceutically effective compositions and methods for treatment of acute occlusive vascular diseases described herein.
  • the animal model employed in the example simulates acute myocardial infarction induced by acute coronary artery thrombus formation and allows evaluation of the risk of reocclusion after successful thrombolysis and of the bleeding risk.
  • a left circumflex coronary artery thrombus was produced as follows: an adjustable screw occluded on the left circumflex coronary artery was tightened to produce a 90 % inhibition of the hyperemic blood flow response to a 20-s occlusion of the coronary artery.
  • a 150 ⁇ A continuous anodal current was applied to the coronary artery electrode placed in the lumen of the artery and attached to the inner surface of the coronary artery and maintained until left circumflex coronary arterial blood flow decreased to and remained at 0 ml/min for at least 3 minutes. Electrical stimulation was delivered for at least 15 minutes.
  • the thrombus was allowed to age for one hour before the thrombolytically active protein was administered.
  • the thrombolytically active protein used for thrombolysis in this example was BM 06.022 disclosed in US Patent No. 5,223,256.
  • the specific activity of BM 06.022 used in this experimental study was 575 000 U/mg.
  • the anticoagulant used was recombinant hirudin produced in Hansenula polymorpha (variant BK-HV).
  • Adjunctive treatment in the reference group was performed with aspirin and heparin.
  • Aspirin was given as an i.v. bolus injection of 20 mg/kg 45 minutes after thrombus formation, i.e., 15 minutes before administration of the thrombolytically active protein.
  • Five minutes later i.e., 50 minutes after thrombus formation - 10 minutes before administration of the thrombolytically active protein
  • heparin was administered as an i.v. bolus injection of 120 IU/kg immediately followed by an continuous i.v. infusion of 80 IU/kg/h of heparin.
  • Adjunctive treatment in the test group was performed with aspirin and hirudin BK-HV.
  • Aspirin was given as an i.v. bolus injection of 20 mg/kg 45 minutes after thrombus formation, i.e., 15 minutes before administration of the thrombolytically active protein.
  • hirudin BK-HV was administered as an i.v. bolus of 6 mg/kg over 1 min.
  • a control experiment was performed with aspirin and hirudin BK-HV infusion.
  • Aspirin was given as an i.v. bolus injection of 20 mg/kg 45 minutes after thrombus formation, i.e., 15 minutes before administration of the thrombolytically active protein.
  • hirudin BK-HV was administered as an i.v. bolus injection of 2 mg/kg immediately followed by a continuous i.v. infusion of 2 mg/kg/h of hirudin BK-HV.
  • the first i.v. bolus injection was performed 60 minutes after thrombus formation.
  • the second i.v. bolus injection was performed 30 minutes later, i.e. there was a time interval of 30 minutes between the bolus injections.
  • Each i.v. bolus injection was given at a dose of 140 kU/kg, i.e., the total dose of BM 06.022 was 280 kU/kg.
  • the experimental observation period was 3.5 hours after the first i.v. bolus injection of BM 06.022.
  • Mean and phasic coronary blood flow were measured.
  • the time to reperfusion was defined as the time from onset of thrombolytic treatment to the time of return of coronary blood flow to 33 % of the control level before occlusion.
  • Cyclical flow reductions were defined as the number of cycles with reperfusion followed by complete reocclusion (zero flow).
  • Plasma samples were obtained before administration of the adjunctive agents and repeatedly after onset of thrombolytic treatment for measurement of the activated partial thromboplastin time (aPTT) according to Larrieu et al.
  • hirudin either as a bolus or as an infusion induced a lower prolongation of the activated partial thromboplastin time (aPTT) than heparin-infusion ( Figure 4).
  • aPTT activated partial thromboplastin time
  • Figure 4 heparin-infusion
  • the 90-minutes bleeding time was reported to be a strong predictor of clinical bleeding (Gimple et al., Circulation 1989; 80: 581-588).
  • the present experiments surprisingly showed that the bleeding time after bolus-hirudin was less prolonged compared with the pretreatment value than after heparin-infusion as well as after hirudin-infusion (100 vs. 135 or 133 %, respectively; Table 3 and Fig. 5).
  • the difference in the bleeding time prolongation between bolus-hirudin and hirudin-infusion is also apparent when compared with published reports of the combination of BM 06.022 and hirudin-infusion (Martin et al., Int J Hematol 1992; 56: 143-153; Table 3).
  • hirudin is concomitantly administered in experimental studies in dogs with coronary artery thrombosis in doses of 6 mg/kg/h infusion (in combination with t-PA: Sitko et al., Circulation 1992; 85: 805-815) or of 2 mg/kg initial i.v. bolus injection plus 2 mg/kg/h i.v.

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Claims (35)

  1. Méthode de préparation d'une combinaison pharmaceutique destinée à être utilisée pour le traitement d'un patient nécessitant un traitement thérapeutique thrombolytique par administration d'une quantité efficace d'une protéine ayant une activité thrombolytique, où la protéine ayant une activité thrombolytique présente une demi-vie qui est plus de deux fois supérieure à celle de l'activateur tissulaire du plasminogène humain et où elle est administrée uniquement par injection d'embol (bolus) et la combinaison pharmaceutique est formulée de façon à fournir un anticoagulant non-héparinique destiné à être utilisé en combinaison avec ladite protéine ayant une activité thrombolytique, et ledit anticoagulant non-héparinique est sous une forme permettant l'administration dudit anticoagulant uniquement par au moins une injection intraveineuse d'embol.
  2. Méthode selon la revendication 1, dans laquelle ladite combinaison pharmaceutique fournit ledit anticoagulant non-héparinique sous une forme permettant deux injections d'embol.
  3. Méthode selon l'une des revendications 1 ou 2 pour la préparation d'une combinaison pharmaceutique destinée à être utilisée dans le traitement préventif de la réocclusion chez un patient après thrombolyse.
  4. Méthode selon l'une quelconque des revendications 1 à 3, dans laquelle la combinaison pharmaceutique est une combinaison en deux parties, permettant à ladite protéine ayant une activité thrombolytique d'être administrée séparément, au moyen de plus d'une injection d'embol.
  5. Méthode selon l'une quelconque des revendications précédentes, dans laquelle la combinaison pharmaceutique est formulée avec ledit anticoagulant non-héparinique en combinaison avec l'héparine.
  6. Méthode selon l'une quelconque des revendications précédentes, dans laquelle ladite protéine ayant une activité thrombolytique est BM 06.022.
  7. Méthode selon la revendication 6, dans laquelle ledit BM 06.022 est présent dans la combinaison pour permettre l'administration sous la forme de deux embols, chacun à une dose de 10 MU, lesdits embols étant appropriés pour être administrés audit patient à 30 minutes d'intervalle.
  8. Méthode selon l'une quelconque des revendications précédentes, dans laquelle ledit anticoagulant est un inhibiteur direct de la thrombine.
  9. Méthode selon l'une quelconque des revendications 1 à 7, dans laquelle ledit anticoagulant est l'hirudine.
  10. Méthode selon l'une quelconque des revendications 1 à 7, dans laquelle ledit anticoagulant est l'hirulogue.
  11. Méthode selon l'une quelconque des revendications 1 à 7, dans laquelle ledit anticoagulant est un agent anti-plaquettaire.
  12. Méthode selon l'une quelconque des revendications précédentes, dans laquelle la combinaison pharmaceutique comprend ledit anticoagulant non-héparinique, ladite protéine ayant une activité thrombolytique et l'héparine.
  13. Méthode selon la revendication 12, dans laquelle ladite combinaison pharmaceutique permet que ladite héparine soit administrée par perfusion intraveineuse ou par voie souscutanée, et qu'elle soit administrée 1 à 2 heures après l'administration de l'anticoagulant non-héparinique.
  14. Méthode selon l'une des revendications 12 et 13, dans laquelle ledit anticoagulant non-héparinique est l'hirudine.
  15. Méthode selon la revendication 10, dans laquelle la combinaison pharmaceutique comprend l'héparine.
  16. Méthode selon l'une des revendications 12 et 13, dans laquelle ledit anticoagulant est l'hirulogue.
  17. Méthode de préparation d'une combinaison pharmaceutique destinée à être utilisée pour diminuer les risques d'hémorragie et d'hémorragie intracérébrale chez un patient, par administration d'une quantité efficace d'une protéine ayant une activité thrombolytique, choisie dans le groupe constitué par la streptokinase, l'urokinase et la pro-urokinase la combinaison pharmaceutique étant formulée de façon à fournir un anticoagulant non-héparinique destiné à être utilisé en combinaison avec ladite protéine ayant une activité thrombolytique et ledit anticoagulant non-héparinique étant sous une forme permettant d'administrer ledit anticoagulant uniquement par au moins une injection intraveineuse d'embol.
  18. Méthode selon la revendication 17, dans laquelle ladite combinaison pharmaceutique fournit ledit anticoagulant non-héparinique sous une forme permettant deux injections d'embol.
  19. Méthode selon la revendication 17 ou 18, dans laquelle la combinaison pharmaceutique est formulée avec ledit anticoagulant non-héparinique en combinaison avec l'héparine.
  20. Méthode selon l'une quelconque des revendications 17 à 19, dans laquelle ledit anticoagulant est un inhibiteur direct de la thrombine.
  21. Méthode selon l'une quelconque des revendications 17 à 19, dans laquelle ledit anticoagulant est l'hirudine.
  22. Méthode selon l'une quelconque des revendications 17 à 19, dans laquelle ledit anticoagulant est l'hirulogue.
  23. Méthode selon l'une quelconque des revendications 17 à 19, dans laquelle ledit anticoagulant est un agent anti-plaquettaire.
  24. Méthode selon l'une quelconque des revendications 17 à 23, dans laquelle la combinaison pharmaceutique comprend ledit anticoagulant non-héparinique, ladite protéine ayant une activité thrombolytique et l'héparine.
  25. Combinaison pharmaceutique ayant la forme d'une unité préconditionnée destinée à être utilisée pour le traitement d'un patient nécessitant un traitement thérapeutique thrombolytique, comprenant des portions séparées respectivement d'une protéine ayant une activité thrombolytique qui présente une demi-vie plus de deux fois supérieure à celle de l'activateur tissulaire du plasminogène humain dans un premier conteneur et d'un anticoagulant non-héparinique dans un second conteneur, la quantité de la protéine ayant une activité thrombolytique et la quantité de l'anticoagulant non-héparinique dans chaque conteneur étant telles, qu'elles permettent l'administration des agents uniquement par injection d'embol.
  26. Combinaison pharmaceutique selon la revendication 25, comprenant au moins deux conteneurs séparés qui contiennent des portions séparées de la protéine ayant une activité thrombolytique, appropriées pour l'administration de la protéine ayant une activité thrombolytique au moyen de deux ou plus de deux injections d'embol.
  27. Combinaison pharmaceutique selon la revendication 25 ou 26, dans laquelle ladite protéine ayant une activité thrombolytique est choisie dans le groupe constitué par BM 06.022 et un activateur du plasminogène du type K1K2P.
  28. Combinaison pharmaceutique selon l'une quelconque des revendications 25 à 27, dans laquelle ledit anticoagulant non-héparinique est l'hirudine ou l'hirulogue.
  29. Combinaison pharmaceutique selon l'une quelconque des revendications 25 à 28, comprenant en outre un conteneur supplémentaire qui contient une portion séparée d'héparine.
  30. Utilisation d'un anticoagulant non-héparinique pour la préparation d'une combinaison pharmaceutique destinée à diminuer les risques d'hémorragie et d'hémorragie intracérébrale chez un patient nécessitant un traitement thérapeutique thrombolytique, ledit patient recevant le traitement thérapeutique thrombolytique par administration d'une quantité efficace d'une protéine ayant une activité thrombolytique, où la protéine ayant une activité thrombolytique présente une demi-vie qui est plus de deux fois supérieure à celle de l'activateur tissulaire du plasminogène humain et est administrée uniquement par injection d'embol et où ledit anticoagulant non-héparinique est sous une forme permettant l'administration dudit anticoagulant uniquement par au moins une injection intraveineuse d'embol.
  31. Utilisation d'un anticoagulant non-héparinique pour la préparation d'une combinaison pharmaceutique destinée à diminuer les risques d'hémorragie et d'hémorragie intracérébrale chez un patient nécessitant un traitement thérapeutique thrombolytique, ledit patient recevant le traitement thérapeutique thrombolytique par administration d'une quantité efficace de streptokinase, d'urokinase ou de pro-urokinase, ledit anticoagulant non-héparinique étant sous une forme qui permet l'administration dudit anticoagulant uniquement par au moins une injection intraveineuse d'embol.
  32. Utilisation selon la revendication 30 ou 31, dans laquelle les unités de conditionnement pharmaceutique sont munies d'instructions concernant l'utilisation de ladite protéine ayant une activité thrombolytique pour permettre l'administration de celle-ci sous la forme de plus d'une injection d'embol.
  33. Utilisation selon la revendication 32, dans laquelle lesdits embols sont administrés audit patient à environ 30 minutes d'intervalle.
  34. Utilisation selon l'une quelconque des revendications 30 à 33, dans laquelle les unités de conditionnement pharmaceutique sont munies d'instructions concernant l'utilisation dudit anticoagulant non-héparinique en combinaison avec l'héparine.
  35. Utilisation selon la revendication 34, dans laquelle ladite héparine est administrée 1-2 heures après l'administration de l'anticoagulant non-héparinique.
EP95912261A 1994-03-25 1995-03-22 Combinaisons de proteines et d'anticoagulants actifs sur le plan thrombolytique, et leurs utilisations Expired - Lifetime EP0751785B2 (fr)

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